BERKELEY, CA (UroToday.com) - The therapeutic goals of treating children with VUR are preventing renal damage and recurrent febrile UTIs.
Treatment modalities and postoperative follow up of children with VUR after endoscopic therapy are still under discussion without defined standards regarding postoperative follow up imaging. Some authors still emphasize the need for a VCUG or a radionuclide cystography in the follow up, but in both cases children are exposed to an extremely displeasing catheterisation and to radiation burden in the former case.
We carried out a minimal invasive protocol for the follow up, focusing on the morphological reconfiguration of the ureteral orifice along the clinical follow-up and performed the postoperative follow up using a real-time 3-dimensional ultrasound (4D-US) examination 1 day after therapy and 3, 9 and 18 months subsequently together with a clinical evaluation. Only children with postoperative UTIs and/or shifted bulk were referred for VCUG.
The aim of this retrospective study with a total number of 178 children was to evaluate visualisation of the injected Dx/HA depot at the ureterovesical junction on real-time 3-dimensional ultrasonography (4D-US) and the correlation of a shifted depot with postoperative UTIs as well as therapy failure in terms of persistent VUR.
Our results show that in 93% of the ureteral units the depot could be detected in the same orthotopic position after 3, 9 and 18 months. None of these children developed urinary tract infections in the postoperative follow up. Only 12 children demonstrated a shifting of the depot. 8 of these 12 (66.7%) patients presented a positive VCUG, 50% of them sustained urinary tract infections. As the endoscopic therapy for primary VUR in experienced hands meanwhile reaches a success rate similar to the success rates of open surgery, it is arguable whether invasive imaging in the follow up could be avoided according to the follow up of open surgery. Close clinical history for febrile UTIs and evaluation of the bladder function together with visualisation of the position of the Dx/HA bulks seems to be a sufficient protocol in the follow up of children treated with Dx/HA.
In our opinion, only in children with postoperative febrile UTIs and/or shifting of the Dx/HA implants a VCUG is justified. The primary aim of treating children with VUR is to prevent recurrent febrile UTIs with subsequent renal damage. In this study no child with orthotopic subureteral augmentation on 4D-US demonstrated postoperative UTI episodes. 4D-US allows identifying children with shifted depot as a possible subsequent treatment failure in form of persistent VUR (incidence 66.7%). In these patients, but also in case of postoperative UTIs, in our opinion a VCUG is always indicated.
Written by:
Renate Pichler, MD., Et Al. as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
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